A nurse is preparing to perform a fundal massage for a postpartum client who is experiencing uterine atony. In which order should the nurse plan to perform the following actions?
Ask the client to lie on her back and with her knees flexed.
Position one hand around the top of the client's fundus and one hand just above the client's symphysis pubis.
Rotate the upper hand to massage the client's uterus while using slight downward pressure to compress the fundus.
Observe the client's perineum for the passage of clots and the amount of bleeding.
The Correct Answer is A, B, C, D
The correct answer is A, B, C, D.
The nurse should plan to perform the following actions in this order:
A. Ask the client to lie on her back and with her knees flexed.
B. Position one hand around the top of the client’s fundus and one hand just above the client’s symphysis pubis.
C. Rotate the upper hand to massage the client’s uterus while using slight downward pressure to compress the fundus.
D. Observe the client’s perineum for the passage of clots and the amount of
bleeding.
Fundal massage is performed to stimulate uterine contractions and prevent
postpartum hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A third-degree perineal laceration is a tear that extends through the vaginal tissue, perineal skin, and perineal muscles and involves the anal sphincter.
This type of laceration requires careful repair and management to prevent complications such as infection, fecal incontinence, and pain.
Choice A is incorrect because abdominal distention is not a contraindication to the use of a suppository.
Choice B is incorrect because afterpains are common postpartum uterine contractions and are not a contraindication to the use of a suppository.
Choice C is incorrect because vaginal candidiasis is a fungal infection and is not a contraindication to the use of a suppository.
Correct Answer is B
Explanation
The nurse should report a fundal height of 38 cm to the provider.
Fundal height is measured from the top of the pubic bone to the top of the uterus and is used to assess fetal growth.
A fundal height measurement that is larger than expected for gestational age may indicate macrosomia, which is a common complication of gestational diabetes mellitus.
Choice A is incorrect because non-pitting pedal edema is common during late pregnancy and is usually caused by physiologic edema resulting from hormone- induced sodium retention.
Choice C is incorrect because 12 fetal movements in an hour are within normal
range.
Choice D is incorrect because a fasting blood glucose level of 90 mg/dL is within normal range for a pregnant woman with gestational diabetes mellitus.
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